Chronicles of an Inner City Hospital Resident Doctor #7

Hi everyone! I'm a 2nd year resident doctor in an inner city hospital. This is a blog to document some of the experiences I encounter as a training doctor, and some of the things that I learn in the process. After all, being a physician means that I'll be learning some fascinating topics for the rest of my career, and seeing how I can use those to help patients.

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Let's get started with today's topic, inspired by some reading I did today:

Left Ventricular Hypertrophy caused by Hypertension

Hypertension, also known as high blood pressure, can be a very dangerous condition! Many people live with undiagnosed or uncontrolled hypertension, not taking appropriate medications or keeping the proper lifestyles to keep their blood pressure in check. High blood pressure has many causes, which include but are not limited to lifestyle, stress, heart problems, blood vessel problems, and kidney problems. The treatment for high blood pressure is dependent on the cause; it’s best to find the underlying cause and address it, resulting in better blood pressure control.

One of the problems that hypertension can cause is known as left ventricular hypertrophy. The left ventricle is a portion of the heart that pumps blood into the aorta, and then out to the rest of the body. Organs will receive the blood supply from this vital portion of the heart. Since the heart is a muscle, when it is under stress, it will grow; this is known as hypertrophy. Thus, left ventricular hypertrophy is growth of the heart muscle in the left ventricle due to stress placed upon the left ventricle. Keep in mind that there are many other causes of left ventricular hypertrophy as well – but this article is dedicated to hypertension! :)

So, how can hypertension cause left ventricular hypertrophy? Well, high blood pressure is a measurement of how the blood within the body is pressing against the walls of the vessels. Thus, when there is a lot of pressure against the vessels, that’s measured as a high blood pressure. When the heart is pumping blood into the left ventricle, it pumps with a high pressure, which stresses the left ventricle to push out more blood. This causes it to grow as an adaptation, so that it can pump out more blood.

How does hypertension causing Left Ventricular Hypertrophy look in a patient?

This is something that we see in our hospital very frequently. It’s very common to see someone with a blood pressure of >180/90 (systolic/diastolic, with normal measurements <120/80). When patients come in with left ventricular hypertrophy with high blood pressure, they’re often complaining of chest pain, shortness of breath, palpitations, or dizziness; less commonly, leg swelling. Of course, the first and most acute thought that comes to mind with chest pain is a heart attack, and we necessarily obtain the appropriate bloodwork and an EKG to rule it out. We would also do this with most of the other symptoms, as they are commonly seen in acute or chronic heart problems.

If the left ventricular hypertrophy and hypertension are isolated problems, the bloodwork will typically not show any substantial abnormalities – at least nothing that would contribute to the problem at hand. We often have patients with multiple relevant problems, so we’re not necessarily so lucky! But, back to this topic...

The EKG, however, will not be normal. This is because there is direct stress upon a portion of the heart, and it shows up on the EKG reading. Below is an example of a reading you might see. Since the left ventricle is located in the front portion of the heart, the electrical leads from the EKG machine that pick up the changes will look different than normal.

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I will openly admit that reading EKGs is not one of my strengths. However, I’ve noticed common patterns, and continue to read about what to look for so that I can recognize it when it occurs. Some common patterns include: ST elevations and deep R waves in the leads corresponding to the left ventricular hypertrophy (I often see them in V1 or V2 through to V6) and left axis deviation (the QRS in leads II, III, and aVF are upside down compared to a normal EKG). In simpler terms, you can see that in leads V1 through V6, several of the lines are bigger, and in II, III, and aVF they’re upside down (a little bit different than the example EKG above).

I will also admit that the first time I saw the ST elevations in person, I thought it was a heart attack - but that’s why it’s important to have the knowledge of other related changes on the EKG, as well as other clinical signs plus lab results. It just goes to show how knowledge goes a very long way and helps you avoid panicking when it’s not necessary.

How can we get rid of Left Ventricular Hypertrophy?

In the case that it’s caused by hypertension, the left ventricular hypertrophy can be treated by addressing the underlying cause: the hypertension itself. We’d give medications that reduce the blood pressure to more normal levels – but not too quickly! Dropping it too fast can cause major problems as well, resulting from decreased blood flow to multiple organs; losing blood to organs can cause them to be deprived of oxygen and nutrients, which can lead to organ damage or even death if it’s for a prolonged period of time.

Now, when we give blood pressure medications, we take a look at the patients’ prior medications and determine whether they’ve been taking them correctly. It’s common for patients to deviate from their regimen, for various reasons (side effects, forgetting, etc.) and that often causes the blood pressure to be high. Based on this, and taking a look at the patient’s medical history and other medications, we can determine how to treat the blood pressure. Certain drugs interact with others, others can be dangerous based on the medical history; this is how we narrow down our options.

Depending on the ability to swallow and how high the blood pressure is, we might use an intravenous medication or an oral one; intravenous is usually used when the pressure is very high and seems to be causing damage to other organs, or if it’s quite high and the patient is unable to swallow. Otherwise, oral medications are preferred. As far as dosage, we typically try to start at the lowest dose possible if we’re unsure about how the blood pressure will respond. It’s always possible to give more if needed, but you can’t take it back once it’s in!

Once the medications are given, you’d see that the blood pressure may come back to more normal levels. This can cause symptoms to reduce or go away altogether, and a repeat EKG would look more normal. If the symptoms don’t get better and/or the EKG isn’t changing, then we would consider looking into further root causes, as sometimes there may be underlying issues that have not yet been discovered or addressed. Let the games of further diagnosis begin!

I hope you've enjoyed this little snippet of a topic I learned as a resident in an inner city hospital. I'll have many more stories and learning experiences coming in the future, so stay tuned.

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Disclaimer: this blog is for entertainment (and possibly educational) purposes only. This is not medical advice. If you have any questions or concerns about your own health, please contact a healthcare provider.

Here are the previous editions of this blog:
Chronicles of an Inner City Hospital Resident Doctor #6
Chronicles of an Inner City Hospital Resident Doctor #5
Chronicles of an Inner City Hospital Resident Doctor #4
Chronicles of an Inner City Hospital Resident Doctor #3
Chronicles of an Inner City Hospital Resident Doctor #2
Chronicles of an Inner City Hospital Resident Doctor #1